Water Fluoridation in Ireland

Fluoridation - S.I. No. 42 of 2007.

The new statutory instrument that governs the fluoridation of public water supplies may be downloaded as a Word file here.

The Code of Practice for Fluoridation of Drinking Water, issued by the Expert Body on Fluoridation, can be downloaded here

Fluoridation Forum Report September 2002 - Executive Summary

Recommendations

1. Policy Aspects of Water Fluoridation

• The fluoridation of piped public water supplies should continue as a public health measure, subject to the other recommendations contained in this report.
• In the light of the best available scientific evidence, the Fluoridation of Water Supplies Regulations, 1965 should be amended to redefine the optimal level of fluoride in drinking water from the present level (0.8 to 1.0 ppm) to between 0.6 and 0.8 ppm, with a target value of 0.7 ppm.
• The amended Regulations should reflect advances in the technology of fluoride monitoring and testing and also the most recent international specifications for the quality of the products used in the fluoridation process.
• An Expert Body should be established to implement the recommendations of the Forum and to advise the Minister for Health and Children on an ongoing basis on all aspects of fluoride and its delivery methods as an established health technology.

2. Technical Aspects of Water Fluoridation

• Guidelines/codes of practice and audit processes should be developed to support ongoing quality assurance of all aspects of the water fluoridation process and should take account of results of both Irish and international research.
• External audit procedures of existing fluoridation plants should be put in place to monitor the performance of fluoridation plants and should be part of the specification of new plants. Audit results should be included in annual reports on water fluoridation produced by relevant fluoride monitoring committees.
• The standards and quality of each fluoridation plant should be assessed and decisions made as to the appropriateness of the continued use of inefficient plants.
• Fluoride monitoring and analytical and reporting procedures should be updated to reflect modern technologies and to facilitate timely reporting of all drinking water fluoride levels. These results should be made available in an appropriate format so that compliance with regulations can be monitored. These results should be freely available for public scrutiny.
• Raw water should be checked for fluoride levels before fluoridation takes place in compliance with the current Regulations.
• The Eastern Regional Health Authority, currently responsible for purchasing the fluoridating products on behalf of the country's health boards, should ensure compliance with the amended Regulations specifying the quality standards of the products used in the fluoridation process.

3. Fluoridated Toothpaste

• The Forum recommends the continued use of fluoride toothpaste in fluoridated and non-fluoridated areas because of the additive benefit from the combination of fluoridated water and fluoride toothpaste.
• Parents should be advised not to use toothpaste when brushing their children's teeth until the age of 2 years. Prior to this age parents can brush their children's teeth with a toothbrush and tap water. Professional advice on the use of fluoride toothpaste should be sought where a child below 2 years of age is considered to be at high risk of developing dental decay.
• Parents should supervise children aged 2 to 7 years when brushing their teeth and should ensure that only a small pea-sized amount of fluoride toothpaste is used and that swallowing of the paste is avoided.
• Paediatric toothpastes with low concentrations of fluoride require further research before the Forum can recommend their use.
• Guidelines for the use of oral health care products in childhood should be developed for use by all involved in advising members of the public on health care matters.

4. Oral Health Industry

• Labelling of fluoride products in a manner which is better understood by the general population and especially by those with low levels of literacy or visual impairment
• The use of clear and understandable instructions on all fluoride product labels, in particular symbols/pictures to describe the appropriate amount of toothpaste to be used by children
• The provision of child resistant containers for mouth rinses and fluoride supplements to prevent inappropriate ingestion of these products by children.

5. Infant Formula

• Infant formula should continue to be reconstituted with boiled tap water in accordance with manufacturers' instructions. Alternatively, ready-to-feed formula can be used.
• The use of bottled water to reconstitute infant formula is not recommended unless the labelling indicates its suitability for such use.
  
  These recommendations are made taking account of Recommendation 3 regarding the appropriate use of fluoride containing toothpaste for young children and Recommendation 1 regarding the reduction in the level of fluoride in drinking water.

6. Fluoride Research

• All future research undertaken should be consistent with the research philosophy as outlined in the Health Research Strategy.
• The Expert Body should prioritise designated research in areas relevant to fluoride, and appropriate funding should be made available.
• Ongoing research related to fluoride should continue to be evaluated by the proposed Expert Body and expanded to deal with new emerging issues.
• Research related to fluoride should include the collection of relevant data on general health.
• In view of the acknowledged importance on a worldwide basis of research in the area of fluoride and oral health, the health board research programmes currently in place should continue and be further developed to augment the world body of information on fluoride for the benefit of all.
• The current 10-year cycle of adult and child dental health surveys should continue. In addition a rolling programme of oral health surveys every second year for a selected age group of children should be implemented.

7. Education, Information and Public Participation

• Media analysis and discussion in both the national and regional press to ensure widespread dissemination of the findings of the Forum
• Further information from the report itself and from the Forum's website
• National and local radio and television coverage to add to this information flow
• Short video presentation of the main issues, accompanied by explanatory leaflets made available to schools and local libraries, for example
• Regional public meetings with a panel of multi disciplinary experts available to present information and to respond to questions and concerns expressed by the general public or by any special interest group. Such meetings, for example could be convened at the request of local interest groups - local authorities, community groups or consumer organisations
• Following completion of this exercise, surveys or other methods undertaken to measure the public response to the findings and recommendations of the Forum in order to help inform policy makers and legislators about public attitudes to water fluoridation.

8. Public Health and Professional Practice

• Oral health as an integral part of general health should be included in the overall provision of health care and in the design of health promotion programmes and initiatives.

Fluoridation Forum website

Download IDA Fluoridation Forum Report (58k)

Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries
Centres for Disease Control document in Word format (42k)

Populations Receiving Optimally Fluoridated Public Drinking Water --- United States, 2000
This report presents state-specific data on the status of water fluoridation in the United States and describes a new surveillance system designed to routinely produce state and national data to monitor fluoridation in the public water supply. The results of this report indicate slow progress toward increasing access to optimally fluoridated water for persons using public water systems. Data from the new surveillance system can heighten public awareness of this effective caries prevention measure and can be used to identify areas where additional health promotion efforts are needed. MORE

 

• There has been more research into water fluoridation than virtually any other public health issue. It has been studied for over 60 years and it's safety has been regularly endorsed by the leading medical and scientific authorities, such as the World Health Organisation (W.H.O.). There is no reliable scientific evidence to link fluoridation to any harmful medical effects. Every major scientific body that has examined the issue has given water fluoridation the thumbs-up on health grounds. Sir Richard Doll, the scientist who establised the incontrovertible link between smoking and lung cancer, is on record as saying "in so far as I can say anything is safe, I say fluoridation is safe". In contrast, the "evidence" being quoted by antifluoridation groups originates from material published on internet web sites. Many of these are anonymous, many are sites of antifluoride groups in the USA, and NONE of them are sites belonging to reputable scientific groups.
• One man's drink is another man's poison. Hydro fluo silicic acid is a by-product of the fertiliser industry, derived from the same mineral source as phosphate. This is not the same as labelling it toxic waste. And the statement that fluoride is more poisonous than lead is meaningless - many nutrients, medications, and even foodstuffs are toxins if the correct dose is exceeded, including vitamins A and D, paracetomol and table salt. Acute fluoride toxicity occurring from the ingestion of optimally fluoridated water is impossible. The amount of fluoride necessary to cause death for a human adult (155 pound man) has been estimated to be 5-10 grams of sodium fluoride, ingested at one time. At 1ppm, equivalent to 1mg/litre, this would require the consumption of 5000-10000 litre of water at one sitting.
• The Irish Government has set an upper fluoride target of 0.8 parts per million in Irish water supplies; in 1988 the EU set a limit of 1.5 parts per million for all EU water fluoridation schemes. The US Environmental Protection Agency (EPA) has set acceptable limits in the United States which are four times higher than those in Ireland. Some readings from Irish sites have occasionally strayed fractionally above 1 part per million,when the target was set at 1 ppm, but mostly the County Councils tend to err on the low side. It should be noted that the EU, while critical of aspects of some Irish water supplies, are perfectly satisfied with the operation of Irish fluoridation schemes.
• 360 million people in over 60 countries benefit from fluoride in the public water supply. Ireland is not the only democracy in the world with public water fluoridation. Approximately 70% of the United States and Australia are fluoridated in this way. The most recent democracy to move to water fluoridation is South Africa. Countries with better dental profiles might not use water fluoridation but they certainly use fluoride. Virtually all of the EU is fluoridated in one way or another. According to the EU Commission, 95% of all toothpaste sales in the EU are of fluoridated toothpastes. Salt fluoridation is far more common in Europe than water fluoridation. But fluoride is fluoride, is it not? If Holland, Sweden, France and other countries have shied away from water fluoridation on health grounds it seems difficult to explain why they are happy to use school fluoride rinsing programmes in Holland, fluoridated milk in Sweden, and fluoridated salt in Germany, France, Belgium and Switzerland. Why are fluoridated toothpastes and rinses not banned in these countries? The reason of course is simple. These countries decided against fluoridation for political or practical reasons, not because of any alleged health effects.
• Political actions contrary to the recommendations of health authorities should not be interpreted as a negative response to fluoridation. While fluoridation is not carried out in Sweden and the Netherlands, both countries support WHO's recommendations regarding fluoridation as a preventive health measure, in addition to the use of fluoride toothpastes, mouthrinses and dietary fluoride supplements. As an alternative to water fluoridation, many European countries have opted for salt fluoridation, in addition to the use of fluoride toothpaste for topical benefits, as a means of bringing the protective benefits of fluoride to the public. Fluoridated salt is available in Switzerland, France, Germany and Spain, and in a further 30 countries world wide. In the Swiss canton of Vaud, bulk commercial salt, and almost all domestic salt, is fluoridated at 250 mg/kg. 75% of the domestic salt sold in Switzerland in 1987-91 was fluoridated. (Basel has water fluoridation.)
• Fluorosis at the level of mottling is extremely rare in Ireland and is associated with sudden large intakes of fluoride (such as from taking fluoride supplements or from swallowing toothpaste as a young child) rather than from water fluoridation. 94% of all dental fluorosis is the very mild to mild form, is not readily apparent to the affected individual or casual observer and often requires a trained specialist to detect.In a 1998 survey in Sligo, there was a higher level of moderate fluorosis among 15-year olds in the non-fluoridated region than in the fluoridated area. There was no severe fluorosis in either region.
• Ireland has the lowest rate of dental decay in 5 year olds in the EU. We have currently one of the lowest rates of decay in 12 and 15 year-olds, though not the lowest. According to all of the non-fluoride criteria quoted by the W.H.O. as relevant determinants of dental decay levels (sugar consumption per capita, National Income per capita and dental manpower availability), Ireland should have one of the worst dental decay profiles in Europe. We have the highest confectionery consumption per capita, the second greatest regional dental manpower inequality and, up to recently, one of the lowest income scores in the EU. Yet we perform extremely well in terms of low decay scores. Why? Because of water fluoridation.
• Sometimes it can be difficult for members of the public to judge the quality of "scientific" information available to them. A very strong hint as to the value of such information can be gained by examining its source. If the source is a widely respected body with strong scientific credentials, such as the World Health Organisation, it carries great weight. If the source is an Internet website, it is best treated with extreme suspicion until its provenance can be determined. Information from lobby groups is naturally biasedtowards their point of view, and often concentrates on maverick studies and academics whose point of view runs counter to that of the scientific community.
• Water fluoridation is ultimately a political decision. In Ireland, had the decision to fluoridate local water supplies been left to local authorities, all the members of such an authority would have had to evaluate the mass of scientific literature on the subject before coming to a decision. They were saved this onerous duty because of a legal challenge to the introduction of fluoridation in Ireland. Not only was the constitutionality of the Act tested in the courts, but the scientific basis for fluoridation was argued by both scientists and lawyers, before its introduction.
• Fluoridation has brought great benefits to the Irish people. If there is a fault on the part of the dental profession it has been in taking fluoridation for granted rather than in publicising its merits. It is safe; it is effective. It is not in anyone's interests to do away with this excellent public health measure as it is the single most effective way of promoting better dental health in this country.